It is generally agreed that there are two concurrent public health crises in the United States: under-treated pain and prescription drug abuse. Although the United States represents only 4% of the world's population, we consume 80% of the global supply of opioids and two-thirds of the world's illegal drugs. Our rising use of prescription opioids for legitimate pain is mirrored by a rising abuse of prescription drugs, in addition to known “street drugs,” and consensus statements agree that the need for substance abuse and addiction therapy in the US is rising and that “treatment as usual” will not be able to meet the demands of the 21st century. It will therefore be necessary to create and adopt new ideas and technologies to reach more patients for improved, or at least equivalent, effective therapy.
Although drug abuse therapy saves lives and healthcare dollars, only a small portion of addicted individuals are enrolled in treatment programs. In 2008, 23 million persons age 12 or older were classified as needing substance abuse treatment although only 10% received treatment at a specialty facility.
Multiple factors contribute to this inequity in treatment—including limited availability of clinical services, difficulty recruiting service providers, limited financing for services and an increasing need in rural communities, where services are most limited. Of course it is well known that many substance abusers refuse therapy, but this does not negate the fact that not enough treatment facilities exist for those who seek therapy.
Most patients are treated in outpatient certification-based opioid treatment programs (OTPs) overseen by various federal agencies. Qualified physicians can also provide opioid addiction therapy in their offices outside OTP clinics, provided they have received specialized training. However, very few physicians have opted to participate in this program and one key reason has been the inability to provide a program of education and counseling services that should be part of an effective therapy.
The principles of drug abuse therapy rely on an induction treatment phase to replace the abused opioid with an opioid agonist or partial agonist to prevent withdrawal symptoms from discontinued illicit drug(s). Most commonly, methadone is used in OTP programs and either buprenorphine (Subutex) or buprenorphine/naloxone (Suboxone) are the preferred treatment regimen for in-office treatment. Following the induction dose, patients can remain on an opioid maintenance dose with careful clinic observation until stabilization occurs with regard to drug craving and abuse with outside opioids or psychogenic drugs. Compliance is documented by frequent urine screening to validate that patients are not taking additional outside illicit drugs. Patient alcohol consumption is also monitored. Patients may ultimately transition to less frequent outpatient follow-up and remain on maintenance therapy or attempt total withdrawal from opioids with careful management and supervision.
Successful treatment programs combine opioid substitution therapy with counseling and addiction recovery programs. Research has shown that behavioral therapies, including cognitive behavior therapy, contingency management, couples and family therapy, and other similar treatments contribute to better long-term outcomes in these programs.
The length of patient retention in a treatment program is the most important indicator of treatment outcome. Recommendations to improve retention include:                individualized medication dosing;        clear program goals;        a clear treatment plan for the patient;        enhanced staff-/patient interactions; and        a reduction in the attendance burden for the patient.Positive incentives (contingency management) and rewards for treatment compliance have a motivating effect on continued therapy. One of the most effective rewards is granting medication take-home privileges to a patient.        
The burden of frequent travel to a therapy clinic also influences clinic retention rates. This may be particularly problematic in rural areas or in cases where transportation is difficult to arrange.